Friday, April 22, 2011

Addiction: A Potentially Fatal Behavioral Disease

A few months ago, an article in the St. Paul Pioneer Press described a "wet house," where people who were unable to stop drinking were able to get housing and access to services without requiring that they stop drinking. A very typical response, especially from people in 12-step programs and in treatment programs, was that this was "giving up" on these unfortunate individuals, that the proper treatment or 12-step participation would result in their being able to sustain abstinence. A number of people have asked me about this. Here's my response to a recent inquiry.


I actually did research on this in the late 1980s and got quite deep into what the best approach was for chronic public inebriates. The problem we were trying to address was that these folks would cycle through the detox center over and over. A minority of users accounted for the majority of visits to detox, which is expensive. In addition they are frequent guests in emergency rooms and hospitals. Here's what we found:

1. Many of them were using detox as a shelter. They were homeless, couldn't maintain a home, and shelters wouldn't take anyone who appeared to be drinking. Some of them would drink a little alcohol and fall down in front of a police car to get transported to detox.
2. For about 1/2 of them, a case manager was able to work with them and get them housed and help them with their food purchases, housekeeping, money management and so forth. This group saw dramatic drops in detox and emergency room usage.
3. The other half were so damaged from their early lives (including many American Indians who were dependent before age 12, and grew up in chaotic environments) that they couldn't form a helping relationship with a case manager. For this group there was nothing we could do to help. Trying to coerce them (e.g., attempt to get control of their disability payments) was counterproductive.
4. All in all providing housing even though people kept drinking was highly cost effective and resulted in better health for the individuals.

There is a similar place in Minneapolis and I know of one in Portland, possibly Seattle.

Here's the sad fact: a small proportion of people with alcohol or drug dependence are unable to quit and will die of their disease. After decades of working with them, I have concluded that any of them would quit drinking or using if they could. Most make multiple efforts. We accept that heart disease, neurological disease and cancer often lead to death in spite of our best efforts and treatments. We have trouble accepting that there are fatal behavioral diseases. This is because we don't think of the brain as an organ. What happens when this organ gets dysfunctional, cannot do its normal job of regulating thinking, feeling, perception, memory, communication, and most importantly here, behavior? Severe, progressive addiction is a result of multiple social, personal, and genetic factors, but the end result is that the individual loses control over their behavior, much like the diabetic loses control of her blood sugar. If you reflect on it, most of our behavior is regulated by unconscious processes that are automatic. It is difficult under good conditions to alter that. Think of smoking, exercise, diet, aggression, how we behave towards our spouses or boss. Our (rational, deliberate) control over our behavior is at best partial. How often do we do something when we are angry that we regret later? Don't all of us have repetitive behavior patterns that are clearly dysfunctional but persist in spite of our best efforts to change them? An example: the fall of Elliot Spitzer, governor of New York, who got caught with a stripper. This was not a rational decision on his part. Another: President Bill Clinton, whose compulsive sexual behavior destroyed his second term.

In addiction, the brain loses the ability to regulate behavior relative to a specific intoxicant. In really severe addiction this loss of control may lead to death. I think that people in this situation are horrified at what is happening to them and terrified that they can't stop it. I've never met an addict who liked being addicted. (They want intoxication, but not addiction.)

In the 1990s, there was a group of us in Minnesota who regularly met to discuss what the optimal approach was to helping public inebriates. We examined everything from locking them up in the state hospital (which is what used to be done), to case management, housing, offering medical and psychiatric services, etc. We concluded that having a safe place for people to live when they can't stop drinking was the best overall solution, most cost effective, most protective of human rights, and most humane.

The idea that someone can stop if they really want to, or if they really work a 12 step program, is a terrible thing. It's not true. Why would brain dysregulation be 100% curable merely by the individual wanting it to be so? We blame obese people for their problems, we blame people who get heart disease for eating too many hamburgers and not exercising enough, we blame people with cancer for not doing the right preventive thing. We do this because it protects us from the terrifying reality that these things occur in spite of everything we can do to prevent them, that our own behavior is not well controlled, that our environment is often responsible for our predicament, or worst of all that it's simply a gene-environment interaction over which we are powerless.

There are many other potentially fatal behavioral disorders, including antisocial personality disorder (death from violence,) anorexia nervosa, depression (suicide,) schizophrenia (suicide, heavy smoking,) obesity and lack of exercise (the second most important cause of preventable mortality,) reckless or distracted driving or speeding, overwork and sleep deprivation, post traumatic stress disorder (suicide, addiction, violence,) uncontrolled aggression (assault and murder,) and addiction to pain killers and sedatives (unintentional overdose.)

I have (clinically) stayed with many people as they died of their addiction. I didn't abandon them because they "didn't get the program" or "didn't really want to get sober." They all did, desperately. But they couldn't. And I couldn't help them. And they died.

Monday, April 18, 2011

Ideology, Attitude and Science: Buyer Beware!

In this new publication, the authors found that both counselor and program characteristics influence counselor attitudes towards use of medications in treating addiction. People who are looking for treatment need to ask about these attitudes prior to agreeing to enter a program or therapeutic relationship. It is a sign of how far the US treatment industry must go when "attitude" determines the treatment you get, rather than evidence based guidelines. And be skeptical when a program or staff member says they use "evidence based practices." Too often, that consists primarily of some training to update counseling skills, but it doesn't involve moving beyond an ideological approach to a scientific one. Consequently, too many treatment staff still see science as useful only insofar as it can validate already held assumptions. We all know, however, that's not how science works. It's designed to upset and surprise because it uses methods to minimize bias. And we're all biased, one way or another. Bottom line: people and families looking for treatment need to educate themselves about the scientific knowledge base of what addiction is and the most current methods available to treat it and then be prepared to ask the program or counselor about specific practices and then to look elsewhere if a program doesn't offer what they are looking for. Consumers can be a significant force in moving the industry forward.

Addictive Behaviors
Volume 36, Issue 6, June 2011, Pages 576-583
Special Issue: Addiction Treatment: Evidence-Based Policy and Practice

Counselor attitudes toward the use of naltrexone in substance abuse treatment: A multi-level modeling approach.

Abraham AJ, Rieckmann T, McNulty T, Kovas AE, Roman PM.

Institute for Behavioral Research, Center for Research on Behavioral Health and Human Services Delivery, University of Georgia, 112 Barrow Hall, Athens, GA 30602, USA; Department of Sociology, University of Georgia, Athens, GA 30602, USA.


Alcohol use disorders (AUDs) continue to be one of the most pervasive and costly of the substance use disorders (SUDs). Despite evidence of clinical effectiveness, adoption of medications for the treatment of AUDs is suboptimal. Low rates of AUD medication adoption have been explained by characteristics of both treatment organizations and individual counselor's attitudes and behaviors. However, few studies have simultaneously examined the impact of organizational-level and counselor-level characteristics on counselor perceptions of EBPs. To address this gap in the literature, we use data from a national sample of 1178 counselors employed in 209 privately funded treatment organizations to examine the effects of organizational and individual counselor characteristics on counselor attitudes toward tablet and injectable naltrexone. Results of hierarchical linear modeling (HLM) show that organizational characteristics (use of tablet/injectable naltrexone in the program, 12-step orientation) were associated with counselor perceptions of naltrexone. Net of organizational characteristics, several counselor level characteristics were associated with attitudes toward tablet and injectable naltrexone including gender, tenure in the field, recovery status, percentage of AUD patients, and receipt of medication-specific training. These findings reveal that counselor receptiveness toward naltrexone is shaped in part by the organizational context in which counselors are embedded.

Friday, April 15, 2011

Concise description of the neurobiology of addiction

In this Baltimore Sun article Dr. David Linden of Johns Hopkins University gives an unusually succinct description of the underlying neurobiology of the development of addiction. Note the interplay between genetics and intoxicant exposure: if you're brain isn't genetically vulnerable, you are not likely to become addicted to a particular drug. Note also that this vulnerability is substance-specific, not a generalized "addictive personality."

Baltimore Sun

Johns Hopkins neuroscientist David Linden explains the biology of pleasure
With his new book, he seeks to find out why vices -- and even virtues -- can hold such sway over our lives

By Mary Carole McCauley, The Baltimore Sun

April 14, 2011

Not all addictions live up to their advance press.

In the past decade, it's become common to casually and humorously describe a favorite activity in the parlance of chemical dependency. People speak of being "addicted" to chocolate or high-fat foods, playing video games, buying expensive designer shoes, watching weekly episodes of "American Idol" to sleeping on high-thread-count sheets. But according to "The Compass of Pleasure," a new book by Johns Hopkins neuroscientist David Linden that is being released today by The Viking Press, just two of those pursuits -- eating fatty foods and shopping -- can become genuine addictions for some people. Watching television, playing World of Warcraft and swaddling yourself in Egyptian cotton probably cannot.

Who knew that feeling good could be so complicated?

"Addiction is defined by the changes that certain activities can make in the brain," Linden says.

"Basically, some activities have been shown to short-circuit the medial forebrain pleasure circuit. The process is the same, whether someone is taking crack cocaine or gambling or having risky sex or shopping. These morphological changes bring about a gradual transition from liking to wanting, and the result is compulsive behavior."

The vast majority of people who pursue habit-forming activities will never become compulsive. Our genes play a major role in determining who will become addicted, how badly and to what substance. It also generally takes repeated exposure for a harmful habit to develop.

For example, Linden points out that for even a drug as highly addictive as heroin, two of every three people who inject the narcotic directly into their veins don't become junkies.

In addition, some pursuits that may technically qualify as addictive carry positive benefits for individuals and society that vastly outweigh the potential harm, such as running a marathon, or an extended bout of contemplative prayer.

"Pleasure is our compass, no matter what we do," Linden says.

"But a philosophical question arises from these findings. If we catch a pleasure buzz from our noblest instincts, does that make them less noble?"

Conversely, just because a substance doesn't create a physical dependency doesn't mean it's safe. LSD might not activate the medial forebrain, but someone who drops acid and jumps off the roof because he thinks he can fly is likely to get hurt.

"There's a whole bunch of risk-taking behaviors that aren't addictive," Linden says. "We're motivated by reasons other than seeking pleasure."

Addiction, he says, is just one form of learning. The changes that occur inside the brain when someone studies calculus are nearly identical to the changes that occurs when he smokes crack.

As Linden explains it, when human beings bliss out by watching a sunset, getting a back rub or drinking a glass of red wine, the ventral tegmental area in our brains is releasing a neurotransmitter called dopamine that is getting picked up by a nearby bundle of neurons called the nucleus accumbens.

Under normal circumstances, pleasure flows and ebbs; dopamine gets released and then reabsorbed for later use. But some activities hijack the pleasure circuit, either by increasing the amount of dopamine flooding into our systems or by blocking the portals through which the chemical messenger goes back into storage.

The result is a jolt of pleasure so intense that most people will do anything to feel it again.

"Addiction is a super-potent experience," Linden says. And, just like Pavlov's dog, "we learn to associate it with sensory cues," he says, "because these associations allow us to predict how to behave so we can repeat the experience."

When we make a connection between, say, our sweet tooth and a chocolate store located in the Inner Harbor, our brains get rewired. After repeated exposure, structures on our neurons called "dendrites" grow new spines. (The same thing happens when we learn our multiplication tables or memorize a new route to work -- both experiences that humans experience as pleasurable, though to a lesser degree and by a more indirect pathway.)

In the future, every time our car turns onto Pratt Street, we may feel a sudden urge from out of the blue to stop at the chocolatier we know is just down the block.

"If you look at the neurons under a microscope," Linden says, "you will see that the receiving ends of their dendrites have turned into a shaggily bush of spines.

"This is how people develop cravings. If you're an addict, the more times you take a drug, the more spines you'll have on your dendrites and the harder it will be to stay clean, because everything you do will trigger those associations."

There's also another problem. As any chocoholic will confirm, no mouthful will ever deliver a burst of flavor as sublime as the very first taste. In scientific jargon, we've become "habituated."

The gradual draining away of pleasure is the process that Linden is talking about when he describes "liking turning into wanting."

"We imagine that addicts experience more pleasure from their drug of choice than others, and that this motivates their compulsive drug-seeking," he says.

"But the research shows that addicts get less pleasure from their drug than other people. The chemical contact between the neurons gets less efficient over time. It gets worn out. As a result, addicts need higher and higher doses to get as much pleasure as they received the first time they took the drug."

Linden acknowledges that one of his motivations for writing this book was political.

"The Compass of Pleasure" argues that as our laws ignore the biological basis of addiction and instead treat the problem as simply a matter of insufficient willpower that can be resolved by punishment.

"Once we understand how the biology of pleasure works," Linden says, "the only reasonable conclusion that we can make is that addiction is a disease. What we're left with is a compassion model, not a model that says that addicts are losers and should be locked up in jail."

He concludes that if addictions of all types rewire the brain, the eventual solution may lie in devising medicines that can bring about permanent changes on a molecular and cellular level that can undo the damage caused by too many doughnuts, cigarettes or trips to the casino.

There's no question that addicts attempting to kick their habit face an uphill battle -- but Linden isn't letting them off the hook.

"The development of an addiction is not the addict's fault," he says.

"But believing that addiction is a disease does not absolve addicts from responsibility for their own recovery. It's not a free ride."

Wednesday, April 13, 2011

The Stigma of Chronic Pain

Most of the patients I treat who have chronic pain are distressed by stigma and the ignorance behind it. They are often judged by relatives, friends, doctors, nurses and others as being weak, addicted, defective, "not tough enough," "not motivated." Worst of all is the epithet: "Drug Seeking." Drug Seeking is a judgment impersonating an objective clinical observation. Drug Seeking implies asking for ("seeking") pain medication for non-legitimate purposes, such as getting high, "being a chemical coper," or other reasons not related to pain control. These judgments are almost always made by people who have never experienced unrelenting severe pain. Pain wears you down. No matter how good you are at coping, it pushes you to the edge. If you have other problems such as chronic physical or mental illnesses, it's just that much harder. The more chronic illnesses you have to manage the harder it is to manage any of them very well. When one illness recurs it upsets all the others. I have had patients who stopped taking opioid (narcotic) medications for pain, even though it improved their quality of life and function substantially, because they were stigmatized and criticized by health care providers, families members, and others. They subsequently are condemned to reduced quality of life and reduced personal and employment function in order to not be labeled "drug seeking." The level of knowledge about the management of pain by most clinicians is minimal at best. Chronic pain frequently goes untreated, leading to considerable suffering and disability because of this stigma.

Bottom line: medication that 1) improves overall quality of life, and 2) improved function in the absence of 3) serious side effects should be regarded as life saving, not as a way to escape reality.


Saturday, April 9, 2011

Message to Chronic Pain Patients: "Cowboy Up!"

In this recent article in the Washington Post, the growing use of opioid treatment agreements is examined. Although increasing in popularity and pushed strongly by the government (read: DEA) these agreements are at best a mixed blessing. This is all part of a growing sense of unease about using opioids in chronic pain, and a move to further restrict access to them. These agreements may do more to protect the prescriber from liability than to protect patients. What is clear to physicians, however, is that there is no liability from refusing to prescribe opioids even if it leads to serious consequences including disability and suicide because patients are held responsible for them. On the other hand, doctors feels the hot breath of the DEA and state medical boards and the threat of malpractice suites very acutely. As with all medications, opioids carry a risk and it is important to minimize it, but even very reasonable risk in the context of substantial benefit is fraught with danger for the physician. It seems that there are plenty of doctors around who will testify against any doctor prescribing opioids for chronic pain. As I have said before, the vacuum created by the lack of good evidence is filled with strong opinion, often passionately held, and usually by those who take a highly moralistic approach to the issue. The end result is not a reduced risk to patients but increasing restriction on access to appropriate opioid medication for chronic pain. This past year, an opioid addicted nurse at a Minneapolis hospital stole a patient's medications that were to be used for his surgery, and told him he was going to have to "cowboy up." He had surgery without analgesia. That pretty well sums up the message to pain patients from regulatory agencies and doctors antagonistic to opioids. This is not going to change until patients and families put the heat on legislatures and Congress to fund more research in this area, and to back off the persecution of doctors who are trying their best to balance risk and benefit in this most terrible affliction.

Some doctors require patients to sign contracts get opioid painkillers

By Michelle Andrews, Monday, April , 4:38 PM

Chronic pain — the kind that lasts for months or recurs regularly — afflicts more than a quarter of adult Americans. Treating pain can be extremely challenging, however, in part because it can’t be measured with instruments. It’s in the eye — or neck or joint — of the beholder.

Doctors often prescribe powerful painkillers called opioids — natural or synthetic versions of opium. Sometimes the prescription is for short-term, acute pain: If you’ve ever had a root canal or surgery or thrown out your back, you may have received a prescription for Percocet or Vicodin, both of which are opioids that also contain acetaminophen.

For people with long-term, persistent pain — often from musculoskeletal injuries or nerve damage — opioids may be the best option to manage their pain and enable them to function day after day.

But there’s a hitch: Though highly effective, these drugs are dangerous and addictive. The chief danger is that they can cause respiratory depression: If too much is taken, breathing slows and may eventually stop. And because they cause euphoria, opioids are popular targets for misuse and abuse. In 2007, 11,499 people in the United States died from opioid overdoses, according to the Centers for Disease Control and Prevention. That was more than the number of overdose deaths for heroin and cocaine combined. To help monitor use of the drugs, some doctors ask patients to sign “pain contracts” or “opioid treatment agreements” that spell out the rules patients must follow to take these drugs safely. The contracts aim to discourage people from taking too much medication, mixing medications, or sharing or selling them, among other things.

The agreements may require patients to submit to blood or urine drug tests, fill their prescriptions at a single pharmacy or refuse to accept pain medication from any other doctor. If patients don’t follow the rules, the agreements often state that doctors may drop them from their practice.

Some patient advocates and policy experts say that rather than ensuring safety, the agreements invade patients’ privacy and damage the trust that’s essential to the doctor-patient relationship.

Joan Crowley started taking an opioid in 2003 to treat recurring migraines and an arthritis-like autoimmune disorder that caused her joints to swell. The drug kept her pain under control and allowed her to continue her work as an accountant in the Pittsburgh area.

A few years ago, her primary-care provider asked her to sign a treatment agreement for the opioid and for Xanax, an anti-anxiety drug she also took regularly. Every three months she visited the doctor so he could evaluate her condition and write her a new round of prescriptions. Sometimes he did a urine test as well.

All went smoothly until this past winter. Crowley, 51, went to the emergency room with what she thought was a heart attack but turned out to be anxiety. While there, she says, she was given an anti-anxiety drug and other medications. The next day she had her regular appointment with her doctor, who gave her prescriptions for her regular drugs and took a urine sample. A week later, she says, she got a telephone call from him, saying that an opioid she wasn’t supposed to be taking had turned up in her urine sample. The doctor gave her 60 days to find a new physician — even after she told him about her ER visit.

Crowley acknowledges that her relationship with the doctor had been strained before that. Still, she was stunned. “This is someone I’d been a patient of for 11 years,” she says. “There was a level of trust there.”

Because of a few high-profile prosecutions of doctors for running “pill mills,” some experts say, doctors increasingly use pain contracts to protect themselves.

The subjective nature of pain makes doctors afraid they’ll be scammed by unscrupulous patients, says Myra Christopher, chief executive of the Center for Practical Bioethics in Kansas City, Mo., who co-authored a recent article critical of pain contracts. “Providers’ primary concern ought to be the management of pain and suffering,” she says. “This shifts the locus of concern to the providers’ protection.”

Others disagree. They say treatment agreements can function as an educational tool and a treatment road map. “It provides a framework to talk about the issues that come up in a treatment plan,” says S. Hughes Melton, a family physician in rural Lebanon, Va., where substance abuse, including addiction to pain medication, is a serious problem.

After working in the mining industry for 22 years, Jeffery Boyd, 50, developed continual pain in his back and legs. Working with Melton, he manages his pain with an opioid and another drug. To Boyd, signing a treatment agreement and being closely monitored by Melton are secondary concerns: Mostly he’s just glad to have his pain under control. “The pain won’t ever go away,” he says, “but [Melton] got me to where I can work at my job and do things.”

That attitude is probably shared by many people with chronic pain, say experts. “Most patients who come in, they just want relief,” says Will Rowe, chief executive of the American Pain Foundation, a consumer advocacy group. “They don’t want to hear about the public-health problem of the misuse of opioids.”

This column is produced through a collaboration between The Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente. E-mail